in 84 days LillyDirect self-pay — Foundayo™ (orforglipron) 2.5 mg moves to $199/month See the changelog
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Express Scripts (Evernorth / Cigna)

PBM standard commercial template (National Preferred Formulary) · updated September 10, 2026

Coverage right now

Kept both Wegovy and Zepbound single-dose pens preferred through the 2025 upheaval. 2026 NPF: Zepbound pens, Wegovy (pens, HD, tablets), and Foundayo all preferred — but Zepbound KwikPens and vials are excluded (device-level steering), and Saxenda is excluded in favour of generic liraglutide. PA criteria run through the Cigna National Formulary policies, which since June 2026 are published one per drug rather than as a single combined document.

Drug status

DrugStatusDetailConfidence
Zepbound® (tirzepatide)Preferred
from Jan 1, 2026
Single-dose pens preferred on the 2026 National Preferred Formulary. KwikPens and vials EXCLUDED (alternatives: Zepbound pens, Wegovy, Foundayo, liraglutide). sourcehigh
Wegovy® (semaglutide injection)Preferred
from Jan 1, 2026
Pens and HD preferred. sourcehigh
Wegovy® tablets (oral semaglutide)Preferred
from Jan 5, 2026
Wegovy tablets preferred on the 2026 NPF. sourcehigh
Foundayo™ (orforglipron)Preferred
from Jul 1, 2026
Listed preferred in the 07/01/2026 NPF — one of the fastest adds of the new oral. sourcehigh
Saxenda® (liraglutide)Excluded
from Jan 1, 2026
Excluded from the 2026 National Preferred Formulary. Listed under 'Excluded Medications/Products at a Glance' with the brand-exclusion-with-generic-equivalent marker, meaning generic liraglutide is the covered agent. Not on the covered PDL. A benefit exclusion is appealed differently from a PA denial. sourcehigh

What these rules come to in dollars — every dose, priced under this coverage:

What preferred, covered and exception only mean
Preferred
On the formulary at the plan's best tier for this class. Usually still needs prior authorization — preferred is not the same as automatic.
Covered
On the formulary, but not the plan's first choice for this class. Often a higher copay tier than a preferred drug.
Non preferred
On the formulary at a disadvantaged tier, or reachable only after trying a preferred drug first.
Exception only
Not routinely covered. Obtainable only through a formulary-exception request that meets the plan's published criteria.
Excluded
Not on the formulary at all. A benefit exclusion is a different fight from a PA denial and is appealed differently.
Varies
The payer's own documents differ by plan or line of business, so a single answer here would be wrong.
Unknown
Not yet verified against a primary document. Recorded as absent rather than guessed.
N/A
Not applicable to this payer.

Prior authorization criteria

high
PA required
Yes, where the plan covers weight loss (EncircleRx adds employer-level eligibility management; participating plans cap member GLP-1 cost at <= $200/month).
Initial BMI
Baseline BMI >= 30, OR baseline BMI >= 27 with >= 1 weight-related comorbidity. Baseline means before any GLP-1 or GLP-1/GIP agonist, so weight already lost on one does not disqualify you. Pediatric (12 to under 18): BMI >= 95th percentile for age and sex, and only on Wegovy INJECTION or liraglutide — Wegovy tablets, Zepbound and Foundayo are adults-only at >= 18.
Comorbidities
Hypertension, T2D, dyslipidemia, OSA, cardiovascular disease, knee osteoarthritis, asthma, COPD, MASLD/NAFLD, PCOS, or coronary artery disease — the broadest published list among major PBMs.
Lifestyle requirement
Trial of behavioral modification and dietary restriction for at least 3 months, AND concomitant use with behavior modification and reduced-calorie diet.
Initial authorization
8 (Wegovy, Zepbound, Foundayo) · 4 (liraglutide/Saxenda)
Reauthorization
Lost >= 5% of baseline body weight (>= 4% liraglutide; pediatric: BMI reduction >= 1%), measured from the same baseline the initial criteria use. Reauthorization lasts 1 year.
Step therapy
None in the PA policy; steering happens at device level via formulary exclusions (KwikPen/vial excluded).
Quantity limits
Zepbound: 2 mL (4 pens or vials) per 28 days retail; 6 mL (12) per 84 days home delivery — no overrides (policy cnf_840). Separately, and across the whole class: only ONE claim for ONE GLP-1 or GLP-1/GIP agonist is approved every 21 days, on fills of a 28-day supply or more, with no overrides recommended for any of Saxenda, Foundayo, Wegovy, Wegovy HD, Wegovy tablets or Zepbound (policy cnf_894, reviewed 01/07/2026, revised 02/04/2026 and 04/08/2026). The 21-day limit APPLIES only to retail fills, but it counts retail and mail history together — so a mail-order fill still uses up the window a later retail fill needs. Switching product mid-month is what it stops.

Primary criteria document: static.cigna.com· static.cigna.com· static.cigna.com· static.cigna.com· static.cigna.com· static.cigna.com

Exceptions and appeals

Appeal deadline
180 days
Deadline detail
180 days from receipt of the adverse determination (Level 2: 90 days).
Exception route
Prescriber ePA via esrx.com/PA, ExpressPAth, CoverMyMeds, or Surescripts. Clinical appeals: Express Scripts, Attn: Clinical Appeals Department, P.O. Box 66588, St. Louis, MO 63166-6588 · fax 877-852-4070 · urgent 800-753-2851.
Turnaround
ESI states nearly all coverage reviews complete within two days of complete information; ePA can return in minutes. Published decision limits: urgent 72 hours, standard pre-service 15 days at retail but 5 days through home delivery, post-service 30 days. The same limits apply again to a level 1 appeal, except that pre-service is 15 days whichever channel you used.
Where
Express Scripts, Attn: Clinical Appeals Department, P.O. Box 66588, St. Louis, MO 63166-6588 · fax 877-852-4070

Source: slu.edu· express-scripts.com

Dated changes

  • Jan 1, 2026 2026 NPF year began — 48 new exclusions, GLP-1 anti-obesity class core retained source
  • Jan 1, 2026 Saxenda excluded from the National Preferred Formulary for the 2026 plan year; generic liraglutide is the covered agent source
  • Jul 1, 2026 NPF document lists Foundayo preferred; Zepbound KwikPens and vials excluded source
  • Jun 17, 2026 Cigna replaced the single weight-loss GLP-1 prior authorization policy with one policy per drug — the criteria did not change, but if you are citing the old combined document in an appeal it now returns a dead link, so quote the policy for your own drug instead source
Criteria cited are Cigna National Formulary coverage policies used with ESI-administered Cigna business; the ESI NPF standard tracks these closely but self-funded clients customize. Widely-indexed secondary sources claim Wegovy injection, Wegovy tablets and Zepbound pens are excluded from the 2026 NPF and that Zepbound vials are the preferred agent — that is backwards, and both of ESI's own PDFs say so. NPE1702 (the covered PDL, effective Jan 1 - Dec 31 2026) lists FOUNDAYO, liraglutide, WEGOVY HD, WEGOVY PENS, WEGOVY TABLETS and ZEPBOUND PEN as covered; the exclusions document lists ZEPBOUND KWIKPENS and ZEPBOUND VIALS as the excluded items, with those same six as their preferred alternatives. Both still carry the PRMT22157-26 and EXCL-NPF-26 (07/01/2026) revision stamps. Trust the primary document — a web search run on 2026-09-10 still returned the backwards version. The combined PA policy this file cited for months, cnf_684, was not merely withdrawn: Cigna SPLIT it into one policy per drug, all reviewed 06/17/2026, which is why the old URL 404s from static, chk.static and v.static alike while its directory neighbours answer. The five successors are cited above and carry the same BMI, comorbidity, lifestyle, duration and reauthorization criteria the combined policy did, read in full on 2026-09-10. The split is also what makes the pediatric line above drug-specific rather than class-wide: only the liraglutide and Wegovy INJECTION policies contain a 12-to-under-18 pathway, and the Wegovy TABLET policy does not, which the single combined document did not let anyone see. Do not cite the EncircleRx benefit-exclusion-override policies as the PA criteria: they now run cnf_1011 through cnf_1020, two per drug, and their own filenames carry their bar — bmi_32 or bmi_35 — so citing one would silently replace the >= 30 / >= 27-with-comorbidity criteria above with a stricter one. That trap has been walked into twice before under the old numbering (ip_0621 at BMI >= 32, cnf_950 at BMI >= 35). cnf_360 is a third shape of the same trap: it is live and its name looks right, but it is the DIABETES GLP-1 policy covering Mounjaro, Ozempic, Rybelsus, Trulicity and Victoza, not a weight-loss policy at all. The appeal block previously rested on an hr.jhu.edu mirror that refused every client for ten days; it now cites a live employer mirror of the same ESI process description, which carries the 180-day, Level-2 90-day, St. Louis address, fax and urgent-phone claims verbatim. It stays MEDIUM because an employer's mirror of ESI's process is not ESI's own publication.
These are each payer's standard template. Employer plans customize them, so the same PBM can cover a drug for one employer and exclude it for another — a status here is a starting point, not your plan. A benefit exclusion is also a different fight from a PA denial. Always request your own plan's criteria in writing; you are entitled to them.